Case

You enter the room to see the next case and find two people. One is the patient and the other is a friend. Before you can introduce yourself, the friend interrupts you to let you know the patient is hard of hearing and needs a sign language interpreter. The patient is stable, so you acknowledge the situation and excuse yourself to arrange interpreter services.

Clinical Question

What is the Emergency Severity Index (ESI), triage pain score, emergency department (ED) length of stay (LOS), and acute ED revisit rate in deaf and hard-of-hearing (DHH) American Sign Language speakers and DHH English speakers who utilize the ED?

Background

DHH patients experience disparities in social outcomes as well as health inequities.¹ This is likely due to audism, which creates privilege for non-DHH people in our society.²

It has been reported that DHH patients are more likely to use the ED than non-DHH patients. However, little research has been done to compare ED-focused outcomes for these two groups of patients.^1,3,4 DHH patients are heterogenous, with adult-onset DHH patients being less likely to use American Sign Language (ASL) with proficiency.⁵ DHH ASL users may also have delays due to interpreter availability, potentially resulting in care discrepancies.^1,6

Reference: James TG, et al. Emergency department condition acuity, length of stay, and revisits among deaf and hard-of-hearing patients: A retrospective chart review. Acad Emerg Med. 2022;29(11):1290-1300.

• Population: Patients presenting to a single academic center for care between June 2011 and April 2020
• Excluded: Patients who had not had an ED visit during that time or who were non-English-speaking
• Intervention: None
• Comparison: Non-DHH English speakers were compared to DHH ASL users and DHH English speakers
• Outcomes: Emergency severity index (ESI), triage pain score, ED length of stay (LOS), and acute ED revisit (defined as within 9 days)
• Type of Study: Retrospective chart review of a single health care system

Authors’ Conclusions

“Our study identified that DHH ASL-users have longer ED LOS than non-DHH English-speakers. Additional research is needed to further explain the association between DHH status and ED care outcomes (including ED LOS, and acute revisit), which may be used to identify intervention targets to improve health equity.”

Results

This study included 100 percent of DHH-ASL people (n=277) and compared them to 1,000 randomly sampled DHH English speakers and 1,000 randomly sampled non-DHH English speakers. During the time frame, 39 percent, 36 percent, and 30 percent, respectively, had an ED visit that could be analyzed. The mean age of the cohort was mid to late 40s, just over half were women, and about two-thirds identified as white.

Key Result

No statistical differences were reported in ESI, triage pain score, or acute ED visits but there was a longer ED LOS observed in DHH ASL patients.

• Emergency Severity Index (ESI): When compared to non-DHH English speakers, neither DHH ASL users nor DHH English speakers had higher odds of being classified into lower-acuity ESI levels.
• Triage Pain Score: On a scale of 0 to 10 the mean score was 5.8 and the median was 7. Neither of the DHH patient groups had pain scale ratings significantly different than non-DHH English speakers.
• Acute ED Revisit: This was defined as a return within nine days; 10 percent of patients had acute revisits to the ED. There was no statistical difference between the groups for this metric.
• Length of Stay (LOS): DHH ASL-using patients stayed in the ED 9 percent longer than non-DHH English-speaking patients (IRR, 1.09; 95 percent CI, 1.05 to 1.13; P=0.016). On average, this equated to approximately 30 min longer ED LOS (95 percent CI, 17 to 44 min). There were no significant differences between DHH English-speaking patients and non-DHH English speakers.

EBM Commentary

1. Cohort Selection: The authors of this study selected the cohort based upon patients who utilized any of the medical center facilities and then select those who presented to the ED, as opposed to just isolating DHH patients from all ED visits.
2. Nine Day Return Visit: It was unusual for the authors to select nine days for the return visit metric. Often in ED literature, we see 72-hour or one-week return visit reported.
3. Length of Stay: The only metric measured that was statistically different was the ED LOS. It was 30 minutes longer in DHH ASL using patients or approximately 9 percent compared to non-DHH English-speaking patients. It is unclear if this is clinically significant, and we should be cautious not to over-interpret single-center, retrospective, observational data.

Skeptic’s Guide Bottom Line

Deaf and hard-of-hearing patients should be triaged and treated with the same level of concern and care as other patients. Use of interpreter services is essential, as with any non-English speaking patient.

Case Resolution

Obtain an on-site interpreter ASL services in your ED. This is preferred to online, remote interpreter systems due to technical difficulties and lack of staff training.⁷

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Thank you to Dr. Corey Heitz, an emergency physician in Roanoke, Virginia, for his help with this review.

Dr. Milne is chief of emergency medicine and chief of staff at South Huron Hospital, Ontario, Canada. He is on the Best Evidence in Emergency Medicine faculty and is creator of the knowledge translation project the Skeptics’ Guide to Emergency Medicine.

References

1. James TG, et al. Conceptual model of emergency department utilization among deaf and hard-of-hearing patients: A critical review. Int J Environ Res Public Health. 2021;18(24):12901.
2. Bauman H-DL. Audism: Exploring the metaphysics of oppression. J Deaf Stud Deaf Educ. 2004;9(2):239–46.
3. McKee MM, et al. Emergency department utilization among deaf American Sign Language users. Disabil Health J. 2015;8(4):573–8.
4. James TG, et al. Emergency department utilization among deaf and hard-of-hearing patients: A retrospective chart review. Disabil Health J. 2022;15(3):101327.
5. Zazove P, et al. Deaf persons’ English reading levels and associations with epidemiological, educational, and cultural factors. J Health Commun. 2013;18(7):760–72.
6. James TG, et al. “They’re not willing to accommodate Deaf patients”: Communication experiences of Deaf American Sign Language users in the emergency department. Qual Health Res. 2022;32(1):48–63.
7. Kushalnagar et al. Video Remote Interpreting Technology in Health Care: Cross-Sectional Study of Deaf Patients’ Experiences. JMIR Rehabil Assist Technol. 2019;6(1):e13233.